Should aspirin (acetylsalicylic acid) be discontinued in a patient with a stent and gastrointestinal (GI) bleeding?

Management of Aspirin in Patients with Stents and GI Bleeding

In a patient with a coronary stent experiencing gastrointestinal (GI) bleeding, aspirin should be temporarily discontinued for a maximum of 5 days, then restarted as soon as hemostasis is achieved, ideally within 24-72 hours after successful endoscopic therapy. 1, 2

Risk Assessment and Decision Algorithm

The management approach requires balancing two competing risks:

1. Stent thrombosis risk - Discontinuing antiplatelet therapy is the strongest independent risk factor for stent thrombosis 3
2. Ongoing GI bleeding risk - Continuing aspirin may worsen active bleeding

Step 1: Assess Stent Thrombosis Risk

• High risk: Recent stent placement (<6 months for drug-eluting stent, <1 month for bare metal stent), history of stent thrombosis, multiple stents, long stents, stents at bifurcations, diabetes, or low ejection fraction 4
• Moderate risk: Stent placement 6-12 months ago
• Low risk: Stent placement >12 months ago

Step 2: Assess GI Bleeding Severity

• Major bleeding: Hemodynamic instability, significant drop in hemoglobin requiring transfusion
• Minor bleeding: Stable patient with minimal hemoglobin drop

Step 3: Management Based on Risk Assessment

For Major GI Bleeding:

1. Temporarily discontinue aspirin for the shortest possible time (maximum 5 days) 4, 2
2. Initiate high-dose IV proton pump inhibitor (PPI) therapy (80 mg bolus followed by 8 mg/h continuous infusion for 72 hours) 2
3. Perform urgent endoscopy within 12-24 hours to achieve hemostasis 4
4. Resume aspirin as soon as hemostasis is achieved, ideally within 24-72 hours after successful endoscopic therapy 2

For Minor GI Bleeding:

1. Consider maintaining aspirin if stent thrombosis risk is high 4
2. Start or increase PPI therapy 4, 1
3. Perform early endoscopy for diagnosis and potential intervention

Special Considerations

Dual Antiplatelet Therapy (DAPT)

• If the patient is on DAPT (aspirin plus P2Y12 inhibitor), consider discontinuing the P2Y12 inhibitor while maintaining aspirin if stent thrombosis risk is high 4
• If both agents must be discontinued due to life-threatening bleeding, prioritize early resumption of aspirin first 4

Dose Considerations

• When restarting aspirin, use the lowest effective dose (75-100 mg daily) to minimize bleeding risk 4, 5
• Higher doses of aspirin (>100 mg) increase bleeding risk without providing additional cardiovascular protection 6, 5

Long-term Management

• Add a PPI for long-term GI protection in all patients requiring continued antiplatelet therapy after GI bleeding 4, 1
• Consider testing for and treating Helicobacter pylori infection, as it increases the risk of aspirin-associated GI bleeding 3

Common Pitfalls to Avoid

• Prolonged discontinuation: Discontinuing aspirin for >5 days significantly increases stent thrombosis risk 4
• Failure to restart: Not restarting aspirin after bleeding control is associated with increased cardiovascular mortality 2
• Inadequate PPI therapy: Insufficient PPI dosing during acute bleeding or after aspirin resumption 4
• Ignoring stent type and timing: Different stent types have different thrombosis risk profiles and timing 4

Remember that the risk of stent thrombosis is highest in the first month after stent placement and decreases over time. The decision to discontinue aspirin must carefully balance the immediate bleeding risk against the potentially catastrophic risk of stent thrombosis.